A comprehensive primary health care approach: improving health outcomes in a remote Indigenous community Anni Kerr 1, Natasha Freeman 1 1 Royal Flying Doctor Service Background The Royal Flying Doctor Service of Australia, Qld Section (RFDS) is one of two organisations funded to manage the Improved Primary Health Care Initiative (IPHCI), in Cape York Peninsula, Far North Queensland. The initiative which is funded by the Office of Aboriginal and Torres Strait Islander Health (OATSIH) Commonwealth Dept of Health and Ageing aims to improve the health outcomes for residents in five remote communities of Cape York (a predominantly Indigenous population). The main strategy for achieving this aim is through the provision of additional health services specifically targeted to address the prevention and treatment of chronic disease. In particular, the project utilises a primary health care approach which aims to make services more accessible, appropriate and sustainable and facilitate community participation in health service planning and delivery. Working in conjunction with IPHCI is the Healthy for Life Program (H4L) which focuses on maternal and child health and the prevention and treatment of chronic disease. The program is funded by OATSIH, auspiced by Qld Health, Cape York Health Service District (CYHSD) and partly sub-contracted to the RFDS. Funding provides for the enhancement of existing RFDS maternal and child health services. The following document provides an overview of the model of care followed by these two programs to deliver a maternal and child health service in one remote community of Cape York Peninsula (Kowanyama). Rationale It is well documented that there is a greater disparity in disease specific mortality rates between Indigenous and non-indigenous populations in Australia. Nearly three times as many Indigenous children die before the age of five compared to their non-indigenous counterparts. Indigenous children experience a greater burden of infectious diseases, the highest rates of bacterial respiratory diseases, a higher prevalence of gastroenteritis (a major cause of hospitalisation), 60% higher dental decay as well as disturbingly high rates of otitis media (middle ear infection). 1,2 Linking the outcomes of nurturing qualities in the environments where children grow up, live and learn, Ritcher 3 acknowledges that important cumulative trajectories can arise in the presence of adverse conditions such as poverty, low birth weight, poor attachment, delayed development and under nutrition. Investing early in a population based approach to maternal, child and family health provides high returns and positive outcomes for children, their families and governments. 4 Parth Wadur is the traditional language of the Kokoberra and Kokoberrin people of Kowanyama region and translates to mean Good Health Healthy Life. It describes the model used to implement a comprehensive Primary Health Care program in Kowanyama. The Kowanyama maternal child and family health model is about sharing information and resources, working from a strengths based approach, encouraging open communication, working with the community and responding to their expressed needs, viewing health holistically and working from a multi-disciplinary framework. 10th NATIONAL RURAL HEALTH CONFERENCE 1
The model demonstrates working in partnership with the Kowanyama community to promote health. It provides the key stakeholders with an opportunity to become aware of the unique aspects of the community, its residents, relationships, physical environment and the social and cultural norms and influences. In an effort to address child health issues, the model generates numerous opportunities to forge powerful local partnerships to deliver shared health goals. The model emphasises that all child health promotion programs and projects require people from different organisations (and disciplines) to work together. 5 All programs within the model have been developed in consultation with local Kowanyama community members, the local Health Action Team, and interagency organisations. The model acknowledges that working collaboratively and in partnership will improve health outcomes for Indigenous people. Characteristics and principles of the Kowanyama Maternal, Child and Family Health Model The Kowanyama maternal, child and family health model is guided by principles of primary health care, health promotion and the Indigenous concept of health. The guiding principles include: CULTURAL RESPECT AND SOCIAL JUSICE: a commitment to cultural respect ensures that the health system upholds the rights and cultural values of Indigenous peoples within a framework of delivering equitable outcomes. RECONCILIATION: a joint approach to implementing practical commitments to build the health and well being of indigenous peoples will improve the relationship and trust between indigenous and non indigenous peoples. HOLISTIC APPROACH: programs consider the impact of family, friends, schools, the community and cultural environment affecting the health of children and young people. COMMUNITY CONTROL/COMMUNITY DECISION MAKING: the model advocates that working in partnership with communities and families is a core responsibility and high priority for the whole sector. Members of the community have a great deal of expertise regarding their own lives and the issues of concern to them. 6 Wass, 7 clearly suggests the process of involving community members in decision making is just as important as the actual decision made. Laverack 8 reiterates this belief as he notes that the decision made is likely to be more valuable because of the involvement of the people themselves in the process. Engaging community members also enables the development of programs specific to local needs and therefore more likely to effective. PROMOTING GOOD HEALTH: health promotion and illness prevention are fundamental components of comprehensive primary health care and must be core activities. 9 Giving people information, opportunities, skills and resources are critical to advancing health, development and well being. BUILDING CAPACITY OF HEALTH SERVICES AND COMMUNITIES: Opportunities to deliver coaching and mentoring to improve the knowledge and skills of key workers has assisted in the upward mobilisation of Indigenous people from the background to the foreground and increases the sustainability of programs and services on the ground. COLLABORATIVE PARNTERHSIPS AND ACCOUNTABILITY: Developing partnerships and mobilising resources through joined up initiatives at local, state and regional levels between health and other sectors, will encourage opportunities for alternative resource allocation that 10th NATIONAL RURAL HEALTH CONFERENCE 2
facilitate targeted health promotion and early intervention across disciplines and sectors (not just those responsible for health promotion). The model is committed to building evidence to track progress for policy, programs and practice. Application The Kowanyama maternal, child and family model is based upon a model of health and interventions for both individual and population health outcomes. The model accommodates disease prevention, lifestyle/behaviourist and socio-ecological approaches supported by collaborative partnerships. As Murphy 10 suggests, it is at this level that the potential to address underlying determinants of social and health outcomes can clearly be recognised. Programs which have developed through the collaborative partnerships of the Kowanyama Maternal, Child and Family Model include: Children and Families Christmas Party Kowanyama Baby Festival Kowanyama Women s Group Core of Life (pregnancy and birthing education program) Nurturing Nutrition Program Kowanyama Playgroup Well Child Health Check Assessment and Screening Program Coaching/Mentorship Program Kowanyama Kids Take Charge Project. Below is a more detailed explanation of two of the above-mentioned programs. The Kowanyama Children and Families Christmas Party (2007 and 2008) This initiative evolved from discussion with staff from the Kowanyama Mothers and Babies Centre, where the child health program operates from. The women working there talked about previous years when there had been Christmas parties and how they would like to celebrate with the young children in the community in some way. The Child Health Nurse was also enthusiastic about acknowledging the community members she had worked closely with throughout the year. These discussions continued over time and became a planning forum for the Kowanyama Children and Families Christmas party. Stakeholders involved in the Christmas Party include the Mothers and Babies Centre, Royal Flying Doctor Service representatives such as the Child Health Nurse, Counsellor, Health Promotion Officer, Medical Officer and Community Support Worker, the Council and Community Development and Employment Program (CDEP) participants, the community store, Justice Centre and Primary Health Care Clinic. Participation in the planning and implementation of this initiative has been inclusive and enthusiastic. Activities on the day included a visit from Father Christmas and the delivery of gifts for all children in the community aged zero to five years of age (coordinated by the RFDS), a large BBQ lunch cooked by CDEP participants with salads prepared by Mothers and Babies Centre staff and games for the children. Outcomes from this initiative have been around increased capacity of local community members in planning events and stronger relationships with RFDS service providers. 10th NATIONAL RURAL HEALTH CONFERENCE 3
The Kowanyama Baby Festival 2008 The Kowanyama Baby Festival 2008 was a collaborative effort from many stakeholders including community members. The Baby Festival aimed to enhance the wellbeing of families in Kowanyama through sharing information and skills with care givers in a safe and fun environment with a focus on developmental stages and expectations for children aged zero to five years of age. In previous years the Baby Festival had included a Baby Competition of the traditional style where children were judged on outfits and hairstyles. For the 2008 Festival it was decided that the Festival had the capacity to promote growth and developmental milestones by making these what the Baby Competition was about. This resulted in a much more interactive affair where care givers increased their knowledge of what activities their child or children should be able to undertake as they assisted in, for example, encouraging their baby to respond to a sound or to hop on each foot depending on the age category. And of course, everyone was a winner! Although many of the children arrived at the Baby Festival looking fantastic, many parents and care givers commented on how much they preferred this type of competition over the focus of previous years. Other activities at the Baby Festival included child health checks, basket weaving, playgroup activities, face painting, baby massage, traditional dance, music and health stalls with information of Foetal Alcohol Syndrome and preparing for having a baby as well as a Pit Stop health screen for adult community members. After a lot of planning and preparation the Baby Festival was declared a success and community and stakeholders began talking immediately about planning for 2009. The event also received very positive media coverage which increased community pride and gave exposure to some of the good things taking place in remote Indigenous communities in Cape York. Conclusion Parth Wadur ( Good Health Healthy Living ) is a comprehensive maternal, child and family health model of care clearly demonstrating the power of partnerships, community engagement, positive relationships and building community capacity. The process of developing partnerships demonstrates the ability to network, collaborate, co-operate and to develop relationships that promote a heightened interdependency among community members. 6 The Kowanyama Maternal, Child and Family Health model aspires to providing leadership by facilitating community groups and providing the enthusiasm and resources necessary to move participation forward. It also enhances access to resources outside the community. 6 All programs and activities that are part of this model aim to involve community members actively in the decision making and implementation process, so that instead of merely being consulted, community members become joint decision makers. Partnerships demonstrate the ability of the community to develop relationships with different groups or organisations, empower individuals and build community capacity. Embarking on a process for change has identified that the most common barriers to progress are as a consequence of infrastructure and systems. The strength of this model has evolved from the participation and collaboration with local people as well as regular and reliable service delivery. Local people have been strong in evolving as leaders within their community and it is time for this model to play a meaningful role in maternal, child and family health through policy development and nursing practice. Community participation structures must be supported to become universal and employ a comprehensive range of responses. 10th NATIONAL RURAL HEALTH CONFERENCE 4
Recommendations This model requires further development in the following areas: Building stronger relationships with men and fathers to better understand and address their needs in relation to positive parenting Building further evidence to track progress for policy, programs and practice Continuing the reorientation of health care services. Further implementation and development of this enhanced model of care demands key stakeholders engage in dialogue with allies whose credibility extends into policy circles and to work collaboratively with communities, local, state and federal government and non government organisations. This model of care is a strategy working towards closing the gap. Policy recommendations A commitment to ongoing funding for primary health care programs and services. Continued support for Primary Health Care programs and services in terms of resourcing and recognition. A commitment to Indigenous Health Promotion development. Implementation of structures and incentives to promote continuity of staff and service. References 1. AIHW Summary Australia s Children: Their health and well being. 2002. 2. Rothstein J, Heazlewood R and Fraser M. Health of Aboriginal and Torres Strait islander children in remote far North Queensland: findings of the Paediatric outreach Service. Journal of Maternal and Child Health 2007; 186(10): 519-521. 3. Richter L. Poverty, underdevelopment and infant mental health. Journal of Paediatrics and Child Health 2003; 39: 243-248. 4. Baum F. The New public Health: an Australian perspective. Melbourne; Oxford University Press, 2002. 5. McMurray A. Community health and wellness: a socio-ecological approach. Mosby Elsevier, Marrickville, 2007. 6. Laverack G. Health promotion practice; building empowered communities. Berkshire, England:McGraw-Hill:Open University Press, 2007. 7. Wass A. Promoting Health: a primary health care approach. Harcourt, 2000. 8. Laverack L. Public health; power, empowerment and professional practice. Palgrave Macmillan, 2005. 9. Keleher H. Chapter 7, Public and Population Health: Strategic Responses. In: Keleher H & Murphy B Editors, Understanding health; a determinants approach. Melbourne, Oxford University Press, 2004. 10. Murphy B. Chapter 11, In search of the fourth dimension of health promotion: guiding principles for action. In: Keleher H & Murphy B. Editors Understanding Health A Determinants Approach. Melbourne; Oxford University Press, 2004. Presenter Anni Kerr is flight nurse for the Royal Flying Doctor Service, Queensland Section. Apart from undertaking emergency retrievals Anni also works as the child health nurse in one of the communities in Cape York. Anni has recently completed a Masters in Primary Health Care. Other qualifications and experience include mid-wifery, adolescent health and emergency services. 10th NATIONAL RURAL HEALTH CONFERENCE 5